Agenda item

To provide an overview and update on the progress of the community and mental health service reviews.

Sarah Mansuralli, Chief Development and Population Health Officer for the NCL ICB, introduced the report on the NCL Community and Mental Health core offer, highlighting that the programme was one that aimed to address historical inequities in access to community and mental health services. She said that, as a new statutory body, the North Central London Integrated Care Board (NCL ICB) had a focus on improving population health and reducing inequalities. It was committed to improving outcomes for residents through an outcomes framework and these community and mental health services were seen as building blocks to delivering proactive integrated care and enable earlier intervention and prevention.

Sarah Mansuralli explained that the strategic review in 2020/21 started with a baseline review of services across NCL which identified a number of inequalities in access and also some differentials in outcomes and spend. This review then led to the co-design of the core offer in partnership with service users and in response to what patients said. The core offer aimed to meet different levels of patient need, including the differing needs of various patient cohorts. Multiple benefits were expected from the core offer and implementation was in progress with an ambitious plan of incremental improvement in services over the next five years.

Natalie Fox, Deputy Chief Executive and Chief Operating Officer at Barnet, Enfield & Haringey Mental Health NHS Trust (BEH-MHT) and also Camden & Islington Foundation Trust (C&I), expanded on this, noting that the core offer involved doing more by working in integrated ways in partnership with other statutory agencies and also local communities and voluntary organisations. The core offer for mental health recognised the variations that existed in the NCL area and was developed with input from clinical staff, experts by experience and local communities across the five boroughs. The core offer developed clarity on access, including what service users could expect from services, what interventions should be provided and the skills and expertise that services should have. The work was linked to the NHS Long Term Plan for Mental Health and placed the service user at the heart of everything that service did. It also aimed to tackle the wider social determinants of mental health which impact on certain patient cohorts, such as the overrepresentation of young black men in mental health services. Through the core offer, services should be developed that people want to engage with and that are accessible for people with physical health conditions or other issues such as learning disabilities. The core offer journey aimed to offer the right care at the right time by the right person. It would also be important to make the workforce more resilient, improve staff satisfaction and offer employment opportunities to the local community through apprenticeships and ‘expert by experience’ roles.

The core offer was split across children and adolescents, young adults, working-age adults and older people with the various models set out in the agenda pack. For children and adolescents, this was based on the THRIVE model which involved a range of interventions to improve access to advice and support. For young adults (aged 18-25) the focus was on a central point of access with service sensitive to cultural and demographic factors that impact on how young people prefer to access care, such as through the ‘Minding the Gap’ mental health support service. For working age adults, there was also a central point of access to a range of services and community provision. For older people there was recognition that there were often more co-morbidities which required more support across different services.

Natalie Fox then responded to questions from the Committee:

• Cllr Connor remarked that there were a number of new initiatives involved with this work and asked how these would be delivered with the community and voluntary sector. Natalie Fox explained that some services were being developed with organisations while others were being commissioned with local providers. With investment coming in there was work ongoing across all five boroughs to pool resources to improve the community offer in partnership with local organisations.
• Asked by Cllr Cohen for further details about the finances, Natalie Fox said that there was a combination of new investment but also a recognition of productivity gains that could be made with existing investment. Sarah Mansuralli added that mental health services had benefitted from a stream of national government funding intended to achieve parity between physical and mental health services. In addition, there were specific service development funding initiatives linked to the long-term plan such as mental health support in schools. While this was not the case for community services, there had been a recognition in NCL that reorganising funding to support people outside of hospital could help to reduce demand on hospital services.
• In response to a request from Cllr Cohen for further details about virtual wards, Natalie Fox said that mental health had been a trailblazer area for virtual wards. This involved multi-disciplinary teams providing face-to-face services to people in their own homes as an alternative to hospital treatment.
• In response to a point from Cllr Atolagbe about the issue of cultural experience, Natalie Fox explained that, by working with experts by experience, this could help to understand how the service offer needed to change. There had also been local work carried out on health population needs. Developing the diversity and inclusion of the workforce could also help to improve the cultural sensitivity of services.
• Asked by Cllr Atolagbe about the lack of female long-term inpatient high dependency rehabilitation beds, Natalie Fox said that the data had been reviewed across the NCL area with a view to looking at how investment could be redeployed. A business case was being developed to look at whether further inpatient services could be provided within the NCL area rather than relying on services outside of NCL.
• Cllr Atolagbe asked how the success of the changes resulting from the Reviews would be judged. Natalie Fox said that there was an outcomes framework as well as long term plan metrics which specified what needed to be delivered included greater access to services. There was also an approach to patient care called DIALOG+ which enabled patients to communicate what they felt their needs were and then looking at whether those needs had been met at various points in time. Several ‘experts by experience’ from the Hive service in Camden, who had been invited to join the meeting, said that they were familiar with the DIALOG+ initiative with one saying that it seemed promising as it enabled feedback to be provided and help guide a way forward. Another explained that he was on a lived experience panel looking at DIALOG+ and that it was generally received favourably by the participants though some found the process to be somewhat mechanistic. Patients were asked to rate their satisfaction with 11 different aspects of their life (e.g. medication, housing, etc.) and those with the lowest scores then formed the basis of a discussion with a therapist to ascertain what action could be taken.
• Cllr Anolue asked whether best practice from previous initiatives were being incorporated into the newer projects. Tina Read, Head of CAMHS Transformation at BEH-MHT, responded that there had been examples of recent collaborative work, including learning from best practice in the Minding the Gap model in the young adult pathway in Camden to help inform other areas, such as transitions. 
• Asked by Cllr Anolue about employment support for people involved with these initiatives, Natalie Fox confirmed that there had been investment in employment specialists in all five boroughs to support those already in employment to retain it, and to assist those out of work in engaging with employment opportunities.
• Asked by Cllr Anolue about staff representation of people of Black African origin, Natalie Fox said that there had been considerable work on staff diversity in BEH-MHT and C&I, including at Director level, across the five boroughs but accepted that there was more work to do. 
• Cllr Revah requested further details about the waiting times to access CAMHS services and the transition to adult services. Tina Read acknowledged that the waiting times for CAMHS services were longer than they would want them to be and work was ongoing to address this, particularly to support young people most at risk in a timely way. She also acknowledged that transition between services could be a particularly difficult time for young people and so the primary focus of Year 1 of the improvement plan for the young adult pathway was the development of transition teams including key workers and clinicians to support young people during this phase. Tina Read said that details of the actual waiting times for transition to adult services could be provided to the Committee in writing. (ACTION)

Kay Isaacs, Director of Operations (North Central Division) at the Central London Community Healthcare Trust, presented details about the adult community services review covering the NCL area. She noted that for many years there had been fragmentation of community services across NCL, leading to inequities. The new core offer for all residents aimed to address this and had been co-produced to improve outcomes. The programme would involve working closely across the five boroughs with primary care, secondary care, social services and the voluntary sector to achieve more joined up services. In the first year of the programme there would be specific work on tissue viability, diabetes, virtual wards, rehabilitation beds, frailty models and long-term conditions. Community providers would be reviewing their local offer to build understanding about where the gaps in provision were and where investment may be needed. The most significant gap found so far was with residents with wounds who were not housebound as they did not have a consistent services across NCL – some may be referred to their GP while others may be advised to go to a walk-in centre – and this had an impact on healing rates. The overall intention was to deliver a local service that meets local needs but with more consistency across NCL.

Vanessa Cooke from the Whittington Health NHS Trust spoke about the aim of reducing variation in the core offer for children and young people’s (CYP) services. As had been said previously about other services, there were a range of providers across NCL with gaps and inconsistencies in some areas and so practical change to work together was important to make better decisions about investment and areas of change. In general, outer London Boroughs had lower investment but there were demand pressures across NCL that could not be met. Slide 37 in the agenda pack provided a summary of the challenges that had been identified and how services would be developed in response. For example, this included investment in health assessments for looked after children across NCL and this required new money in four of the boroughs to increase provision and reduce variation. By building early intervention and having good universal support for all children, this could avoid the need for more targeted and specialist support in future, reducing long-term demand pressures.

Seema Islam, Chair of the ‘Our Voices’ parent carer forum in Enfield, explained that the sooner that intervention and access to services for children with autism/ADHD took place, irrespective of when diagnosis was made, the sooner the quality of life improved for them.

The experts by experience then described their use of the Hive service in Camden, which was described as a dynamic, preventative service. Helena said that she had been visiting the Hive for three years after a recommendation from her GP and had accessed a number of services including one-to-one meetings, a women’s group and an LGBT group. She said that the Hive provided a good multi-faceted service but unfortunately this type of service was not available to many people in other boroughs. She also highlighted the higher accessibility of the Hive in comparison to some other NHS mental health services.

Nick explained that following his autism diagnosis, he found that the service offer to him was very limited as he was regarded to be high functioning. He felt that access to informal drop-in support would be very helpful, rather than having to go through his GP for everything, particularly because GP appointments were difficult to obtain at present.

Cllr Connor asked whether this service model could be replicated elsewhere. Sarah Mansuralli said that the overall plan was to recognise where there was good practice, look at the gap analysis and then go through a prioritisation exercise as resources were limited. This meant that, while services like the Hive might not be available across the whole of NCL by next year, services and the workforce required, would be built up incrementally. Natalie Fox added that there had been considerable investment recently in crisis cafes and drop-in centres across all five boroughs, but acknowledged that there was more work to do in reaching people.

Committee Members then asked questions to those present:

• Asked by Cllr Clarke about the definition of prevention, Vanessa Cooke said that prevention was about helping people to stay well and meeting their needs at the point they were at. In the context of CYP services she said that this was about young people being able to access support in a timely way when they need it rather than waiting until their issues became more complex.
• Asked by Cllr Clarke about the use of dialectical behaviour therapy, one of the experts by experience described this as an approach for people with complex emotional needs that included mindfulness and relies on the person getting in touch with their emotions.
• Cllr Revah highlighted the importance of early intervention for people with autism, including because of the difficulties that can be experienced in education settings if it is undiagnosed. Seema Islam responded that there was an ongoing ‘autism in schools’ project supporting parents and schools to work more closely together. She emphasised that children having their needs met was more important than having a diagnosis. Vanessa Cooke added that other work with schools included joint training and the Senco forums which were attended by representatives of autism services. Sarah Mansuralli added that networking between groups of schools could help to spread learning in this area. Vanessa Cooke acknowledged that long waits for diagnosis was a big issue and said that a significant amount of one-off investment was being provided to increase capacity across NCL, targeted at children and young people who had been waiting the longest.
• In response to a point from Cllr Revah about support for parents, Natalie Fox said that the care packages provided were for the parents as well as the children with an allocated key worker. There were also community navigators that worked with families over a longer period of time.
• Cllr Anolue commented that autism diagnosis was particularly important as parents needed to know what their child needs support for and what services they need to access. Seema Islam responded that it was still important to children to be able to access service before diagnosis in order to prevent deterioration. Vanessa Cooke added that there was a range of support available before diagnosis but it was recognised that more was needed at an earlier stage. Nick added that diagnosis opened a lot of doors in terms of access to certain services and entitlements.
• Asked by Cllr Connor how long the autism/ADHD assessment waiting times currently were, Vanessa Cooke said that this varied across NCL and that there were complexities due to different providers and different types of assessment processes. Although more resources were being provided, referral numbers in the past 6-12 months had risen so this was impacting on waiting times. Some specific data on this could be provided to the Committee in writing. (ACTION)
• Asked by Cllr Atolagbe about signposting to mental health support for parents and children, Sarah Mansuralli commented that service users are sometimes concerned on a Friday about accessing support over the weekend and weren’t always aware of support available such as crisis cafes. She felt that there was potential to promote this information more widely, including online.

Alex Tambourides, Chief Executive of MIND in Enfield & Barnet, then spoke about the work of the organisation, noting that it sees around 5,000 people with mental health issues per year and for MIND organisations across the NCL area this figure was around 20,000 people per year. He added that 77% of their staff had lived experience of mental health issues. He said that a recent Mental Health Trust document had pointed out that most positive outcomes for mental health issues had a social route. However, the levels of investment required for such support did not match clinical funding. For MIND, prevention was at the core of their work and they provided a well-being network, with therapy and integrated services provided in partnership with the Mental Health Trust. They also ran a crisis café in Barnet at which around 800 people were supported per year, though more could be done with additional funding and staff. He added that more one-to-one support workers were needed in mental health as opposed to more social prescribers and community navigators.

Lynette Charles, Chief Executive of Mind in Haringey, said that MIND organisations across London recognised that they needed to fill gaps on the ground. She welcomed the core offer and that what was needed on the ground was a needs-led framework to help address issues that people were facing such as problems with the cost of living and the huge demand for housing. There were also concerns with the precarious situation in the voluntary sector waiting to find out whether contracts held with statutory partners would be renewed. Other concerns of residents around services remained basic issues such as the ability to contact home treatment teams or care coordinators and so they were not currently seeing the transformation in services.

Ruth Glover, Clinical Director at Open Door, explained that her organisation provided a voluntary sector mental health service including talking therapies in Haringey for 12-25 year olds and their parents and carers. Most of the team had been trained in the NHS. Their service user issues included autism/ADHD, children in care and involvement in youth violence. The age range of 12 to 25 that they supported meant that the transition stage was covered which could be a challenging time and when young people needed the space and time to talk. About a third of the young adults that used the service were recognised as neurodiverse, though this figure could be significantly higher in reality. Demand and the number of referrals to the service had increased in recent years but this had not been matched by funding and so it had been necessary to close the waiting list for a time. Some new funding had now been received and there were currently around 50 young people on the waiting list. As well as an increase in the overall demand for services there was also an increase in the complexity of need. As this was happening across the sector, this presented recruitment and staff retention challenges.

Committee Members then asked further questions:

• Asked by Cllr Connor about the challenges in stability and funding for voluntary organisations, Natalie Fox said that a large proportion of the investment into the core offer was going to the voluntary and community sector. This included experts by experience and peer support coming into the offer. BEH-MHT and C&I recognised that a partnership strategy with the voluntary sector was needed to improve joint working processes. Alex Tambourides commented that voluntary sector organisations were very small compared to statutory partners and said that it was good to hear about a partnership strategy but it was necessary to work out what each organisation was responsible for. MIND provided IAPT services in Enfield and Barnet and MIND in London ran services for people on CAMHS waiting lists and this all required funding to keep going. Ruth Glover added that better access to psychiatry was needed due to the increased level of complexity that was being seen.
• Cllr Milne asked what progress was being made to enable service users to only have to provide their information once, as doing so multiple times could be frustrating for people. Natalie Fox said that NCL ICB currently had a project looking at healthy information exchange with providers able to add and access patient information. Sarah Mansuralli added that this brought a variety of data sets together but that it was taking some time for all Trusts to add their data and keep it updated in real time. Alex Tambourides commented that data sharing was moving in the right direction and suggested that wider use of information passports which allows people to transfer their information between organisations, including voluntary sector organisations. Ruth Glover added that trusted joint assessments could help in this area.
• Cllr Hutton raised the wider issue of communications with residents, including how widely available information about services was, including information being provided in a culturally appropriate way.  Natalie Fox acknowledged that there was a big piece of work to do on communications and ensuring that people can easily get information about accessing services.
• Referring to the investments on slide 37 (page 49) in the agenda pack, Cllr Cohen asked about the sources of the funding for these and how many years they lasted for. It was agreed that further information on this would be provided to the Committee in writing. (ACTION) Cllr Connor noted that there were also requirements for savings on the slides. Kay Isaacs reported that there was an error on page 55 of the agenda pack and that where it stated 211,000 bed days this should actually read 21,000 bed days.
• Cllr Chowdhury raised concerns about the resilience of the workforce and the short-term nature of some funding for service providers. Lynette Charles and Alex Tambourides also highlighted challenges with instability in funding arrangements. Natalie Fox acknowledged that smaller pots of short-term funding could cause difficulties and observed that this was an issue in the statutory sector as well as the voluntary sector. She also referred to the NHS People Promise, recognising that staff across a lot of services had been through a difficult time so there was an issue about resilience, wellbeing and supporting staff.
• Cllr Connor explained that Councillors often experienced issues in local communities with people in mental health crisis who typically came into contact with the Police rather than mental health teams and asked what was being done to address this. Natalie Fox responded that community transformation was about engaging with service users earlier in order to prevent them from reaching crisis point. The other active piece of work was liaising with the Police so that they could contact mental services and direct people to alternative care options rather than using S136 (under the Mental Health Act). Each Borough also had a mental health liaison officer.
• Nick referred to an recent government announcement about ‘mental health ambulances’ which was based on the idea that these emergency vehicles, staffed by people with mental health training, were better placed than the Police in dealing with an individual in crisis, assessing them and transporting them to the most appropriate location. Natalie Fox confirmed that they were already engaged with this project in NCL. Lynette Charles highlighted the adverse impact on the black community in S135/136 police interactions and reported that MIND has provided training to 192 police officers on mental health awareness to help them in these situations.

The Committee than made recommendations for a follow-up agenda item:

• That an updated report on the mental health and community health service reviews be provided to a meeting of the Committee in approximately 12 months time.
• That the updated report should cover a range of issues of interest to the Committee including:

o   Partnership working with the voluntary sector.

o   How well signposting was working and how the availability of services was being promoted/communicated to residents.

o   What support was provided when voluntary services were not able to cope with demand (such as when Open Door were forced to close their waiting list)

o   The availability of advocacy & patient support and the availability of psychiatric support.

o   Waiting times for autism/ADHD diagnosis.

o   Progress on support for the workforce and recruitment/retention.

o   Challenges with the use of small, limited pots of funding to provide services.

o   The social route of mental health support, such as cost of living and housing issues.

o   The service offer for older people.

o   Police S135/136 interactions and the ‘mental health ambulances’ project.

o   The cultural sensitivity of services.

o   Support for people with disabilities.